professor johanna westbrook - australian institute of health innovation
TRANSCRIPT
A collaborative Australian-UK study to measure
the impact of eMM on the work of hospital
pharmacists
eMedication Management Conference
14-15 March 2017, Sydney
Research Team Members
UK Team: S Shah, A Girling, A Slee, J Coleman, K
Cresswell, B Schofield, L McCloughan, A Sheikh
Australian Team: L Li, E Lehnbom, M Prgomet,
J Westbrook
EMMs are promoted for their ability to improve
work efficiency and safety
- Less time on administrative tasks
- More time for patient care - Fewer errors
Research Evidence of Impact on Work
• Quantitative evidence is sparse
• Most studies on doctors’ work in ambulatory care and critical care
• Know little about the impact on nurses
• Hospital pharmacists’ work likely to be significantly affected, but little research quantifying how work changes
Capturing the multi-dimensions of work challenging
Self-reported patterns of work unreliable
Direct observations of work more accurate
Methodological Challenges
Direct Observations Nurses & Doctors
70 nurses observed for 276.9 hours 59 doctors observed for 356.3 hours
Measured changes in how nurses and doctors distributed their time across work tasks in controlled pre and post eMM studies
• Nurses and Doctors with eMM experienced no significant
changes in % of time spent on:
Medication Tasks;
Direct Care;
Professional Communication
Compared to control wards without eMM
• Doctors with eMM spent more time with other doctors
(p=0.003) and with patients (p=.009).
• Nurses with eMM spent less time with doctors (p=0.0001).
Results
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Serious prescribing errors
Intervention wards – significant 44% (p=0.0002) reduction in serious prescribing error rate 25/100 admissions 14/100 admissions (95%CI 21-29) (95%CI 10-18) No significant change on the control wards (p=0.4)
International Collaboration
Aim: To undertake parallel observational studies
of pharmacists in hospitals in the UK and
Australia using the same methods
Methods Pharmacy work task classification developed
Iterative approach between UK & Australian teams
Australian & UK similar pharmacist training & practice
11 broad categories of work – defined by inclusion/exclusion criteria
Pilot tested & incorporated into WOMBAT software on handheld tablet computer
Examined changes in % of time in task categories pre/post
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Example of task definitions
History taking Process of taking a medication history, reconciling
medications at anytime Includes Excludes All things historical
Collecting data from a patient, carer or relative to record on a medication history and reconciliation form (paper or electronic) Faxing/phoning GP, local pharmacy
Accessing summary care/electronic health record
Verifying medications taken prior to admission
Includes reconciliation of a patient’s own drugs
Asking about allergies
Asking about medications that have been started in hospital
Review
Transcribing
Providing medication information
Pre- and post- WOMBAT observational study of pharmacists
UK
Hospital
Australian
Hospital
No. of beds 600 538
No. of
pharmacists obs 11 12
No. Obs. Hours
Pre 135.7 80.4
No. Obs. Hours
Post 119.3 74.1
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Changes expected Post eMM
Pharmacists:
Review medication charts online
Access medication information in real time
Integration of order verification/medication order review with dispensing
Potential Effects on Work:
Release time to spend on patient education/discussion
Reduce time in medication review as fewer errors, legible orders
Changes in % of pharmacists’ time on tasks, with others
and interruptions pre post eMM
Significant pre/post change
*P<0.05 ** P<0.01 UK Hospital
Pre – Post %
Australian Hospital
Pre – Post %
Medication reviews 27.1 32.6* 12.5 27.5*
Non-clinical tasks 15.7 NC 21.0 NC
Work-related discussion 3.5 2.6** 12.5 NC
History taking 19.4 29.5** 7.6 13.3**
Supply medications 9.9 5.8** 6.0 3.1*
Time with patients 7.3 NC 5.6 10.2**
Time with doctors 4.9 NC 7.3 14.8**
Time with nurses 3.5 NC 6.5 12.4**
Tasks interrupted 3.2/hr 2.7/hr** 4.2/hr NC
NC = No Change
Considerable differences in countries at baseline which persisted
Australian pharmacists engaged in more inter-professional interactions & interrupted more frequently
Major changes in the same direction – increases in medication review and history taking
UK 30% on history taking v 13% Aust- performance indicator for review of patients in 24 hours
Reduced time in medication review not evident
Australian pharmacists spent more time with patients post
Key Findings
Pharmacists’ views of eMMS from a
Children’s Hospital
Team: M Baysari, R Hardy, L Richardson, R Lake
Background
17 pharmacists
Interviews around 4 months post eMM
Included outpatient, inpatient, oncology and
pharmacy managers
Questions about: overall impression of
eMM, changes to work, safety risks/benefits
Themes which help to understand the quantitative data
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Changes to work
Addition and changed tasks:
Helping doctors and nurses use the
eMMS;
• “I think we were also expected to understand, especially
from the doctors’ perspective, they call us a lot and say,
“How do I do this, how do I use this?”
• “There’s 10 to 20 minutes of helping doctors figuring –
navigating – that I otherwise wouldn’t have had to do”.
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Training
Training viewed as insufficient and completed too early
• “Although I did have some training sessions earlier on
that was too far away from the actual implementation of
the system to be of any use”
• “But that’s also hard because we haven’t been trained
properly anyhow so we get doctors ringing on a daily
basis, saying, “Can you tell me how to do this discharge?”
I would love to help them but we haven’t had adequate
training to be able to”.
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Improved safety
Most pharmacists said that the eMMS improved
visibility of medication information
• “You can now see all of the patient’s medications which is
really nice when you have a complex patient who might
be on multiple medications and their drug interactions and
things, whereas previously we were just seeing one
section of the chart, and kind of making a judgment based
on that”.
Observational studies and interviews allow testing
of hypotheses about expected work practice
change.
Comparisons provide insights into the potential
impact of context, implementation processes and
system design on work
UK - This is a summary of independent research funded by the
National Institute for Health Research (NIHR) under its Programme
Grants for Applied Research scheme (RP-PG-1209-10099).
The views expressed are those of the author(s) and not necessarily
those of the NHS, the NIHR or the Department of Health.
AUSTRALIA – This research was partly funded by an NHMRC Program
Grant
FUNDING STATEMENT
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